A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Stop the transfusion.

Obtain a prescription for a diuretic.

Place the client in high-Fowlers position.

Administer epinephrine to the client.

Administer oxygen to the client

Answer and Explanation

Correct Answer : A,C,E

Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.

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Correct Answer is C

Explanation

Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.

A. Document the largest line the client can read on the chart. B. Begin by testing the client while they are wearing glasses. C. Position the client 3.3m (10 feet) away from the chart D. Instruct the client to begin the assessment with both eyes open.

Correct Answer is B

Explanation

The nurse should begin by testing the client while they are wearing glasses, as this reflects their usual visual acuity. The nurse should document the smallest line that the client can read on the chart, not the largest. The nurse should position the client 6m (20 feet) away from the chart, not 3.3m (10 feet). The nurse should instruct the client to begin the assessment with one eye covered and then switch to cover the other eye.

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A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Correct Answer is C

Explanation

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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